A Prospective Comparison of Cardiac Imaging Using Intracardiac Echocardiography With Transesophageal Echocardiography in Patients With Atrial Fibrillation

Watchman Device: Left Atrial Appendage Closure For Stroke Prophylaxis In Atrial Fibrillation

A concerning proportion of patients with atrial fibrillation (AF) with indications for oral anticoagulation (OAC) discontinue OAC or are never prescribed OAC therapy and many AF patients with the highest risk for embolic events off OAC also have the greatest risk for hemorrhagic complications on OACs. Medium-term efficacy and safety data provide evidence that the WATCHMAN device, the most studied device and the only one with randomized and medium-term follow-up data, may be a viable alternative to chronic warfarin therapy in nonvalvular AF patients. In addition to presenting key data pertaining to LAA closure techniques including the WATCHMAN device, this review will discuss crucial WATCHMAN implantation technical points.

Cost analysis of periprocedural imaging in patients undergoing catheter ablation for atrial fibrillation

Cardiovascular imaging is an important part of procedural planning and safety for catheter ablation of atrial fibrillation (AF). However, the costs of imaging surrounding catheter ablation of AF have not been described. Medicare fee-for-service data were used to evaluate Medicare expenditures before, during, and after catheter ablation for AF from July 2007 to December 2009. Among 11,525 patients who underwent catheter ablation for AF, the mean overall expenditure on the day of the procedure was $14,455 (SD $7,441). The mean imaging expenditure in the periprocedural period, which included the 30 days before the catheter ablation and the day of the ablation itself, was $884 (SD $455). Periprocedural imaging expenditures varied by the imaging strategy used, ranging from a mean of $557 (SD $269) for patients with electroanatomic mapping only to $1,234 (SD $461) for patients with electroanatomic mapping, transesophageal echocardiogram, and computed tomography or magnetic resonance imaging. Mean patient-level imaging expenditures varied by provider (mean $872, SD $249). Periprocedural imaging expenditures also varied by patient risk, with mean expenditures of $862 (SD $444) for patients with a CHADS2 score of ≥2 compared with $907 (SD $466) for CHADS2 score<2 (p<0.001). In conclusion, periprocedural imaging accounts for approximately 6% of mean Medicare expenditures for catheter ablation of AF. The expenditures for periprocedural imaging vary both at the patient and at the provider level and they are inversely related to stroke risk by CHADS2 score.

Techniques To Improve Left Atrial Appendage Imaging

The clinical importance of the left atrial appendage (LAA) is increasingly recognized. The assessment of the unique anatomy and function of the LAA is especially important in the setting of atrial fibrillation (AF). AF is the most commonly occurring cardiac arrhythmia, and the association of LAA thrombi and AF has been well established. Transesophageal echocardiography (TEE) is a widely available imaging tool to exclude the potential presence of LAA thrombus prior to cardioversion in patients with AF. Commercially available products containing microbubbles to enhance ultrasound images, termed "ultrasound contrast agents" (UCA) are indicated for use with transthoracic echocardiography to improve cardiac structure and function assessment, but can also be used with TEE as an adjunctive tool to assess the LAA. Integrative multimodality imaging techniques can be used in evaluation of the LAA as indicated in various clinical scenarios including: stroke risk assessment, decision-making prior to cardioversion in AF, placement and assessment percutaneous transcatheter LAA occlusion procedures, and assessment of results of procedural or surgical exclusion of LAA. In this article, various imaging techniques that are available for non-invasive visualization of the LAA will be reviewed along with the clinical importance of assessment of LAA anatomy and function.

The Evolving Utility Of Intracardiac Echocardiography In Cardiac Procedures

Intracardiac echocardiography (ICE) has gained increasing use in electrophysiology due to the need to visualize key anatomic structures. Precise guidance for transseptal puncture and visualization of the pulmonary veins are common essential uses for ICE, but many operators adept at ICE imaging have developed additional and specific uses. With heavy use of ICE guidance, electrophysiologists demonstrated feasibility of left atrial ablation with minimal use of fluoroscopy. With the advent of 3D mapping-integrated ICE, rendering of contours for the left atrium, aortic cusps, and left ventricular structures such as the papillary muscles have become possible. Improved understanding of the anatomy of these areas can facilitate mapping and ablation of these structurally complex sites. Additional uses of scar-visualization and integration into voltage maps have been explored. Left atrial appendage imaging has been an area of interest in the ICE community, although technological improvements are likely needed to make this more reliably complete. A new real-time 3D ICE catheter has also been developed, and work is in progress to delineate potential uses for this new frontier. Increasingly routine use of ICE has led to improved real-time guidance of all percutaneous cardiac procedures.

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.

The Editors. Circulation: Arrhythmia and Electrophysiology Editors' Picks

The following articles are being highlighted as part of the Circulation: Arrhythmia and Electrophysiology Topic Review series. This series will summarize the most important manuscripts, as selected by the editors, published in Circulation: Arrhythmia and Electrophysiology and the rest of the Circulation portfolio. The studies included in this article represent the most-read articles published on the topic of atrial fibrillation in 2009 and 2010.